Dental Intelligence

William Tracy Brown

May 2012-Blog

The message on the front door of a restaurant in Austin, Texas reads:

“If we don’t meet your expectations, lower your expectations.”

I thought about my dental practice when I read the notice.  Do we meet our client’s expectations? Do they need to lower their expectations after they visit?

What are their expectations?  How does our office meet or surpass the expectations?

An emergency patient, new to our practice, made me realize I might need to put the above notice on the front door of our state-of-the-art office.

The patient was a self-made, successful contractor/developer.  He fractured the two front false teeth on his “flipper” partial.  It was early Monday morning and he had a busy week scheduled.  But now he had to deal with teeth that affected more than his mouth.

The “flipper” had been delivered 15 years ago as a temporary.  To him it was perfectly serviceable, until he bit into a chop bone. I thought of telling him all dental restorations were temporary; some more temporary than others.

His expectation was to get the thing fixed “yesterday”.  My expectation was a four-unit fixed prosthesis.

I went into elaborate explanation about how wonderful a new bridge would be.  I didn’t notice how exasperated he was becoming.  He was double-parked and his engine was revved.  Instead of doing a quickie repair and rescheduling the hard-charging man, I was telling him how I was going fix his teeth.

To him, he asked for the time of day and I was telling him how to make a watch.

He finally shook his head, took off the napkin chained around his neck and left without a goodbye.

I was confused. What had I done to offend him?  I thought I was doing him a favor.

My staff explained to me that I hadn’t met his expectations.  They were correct; I hadn’t.

That was the day I began giving serious thought to expectations.

What were my expectations?

He expected me to fix his front teeth PDQ.  I didn’t and he left.

I realized I should have taken care of his chief concern as quickly as possible, told him the “Spackle” repair would fail in the near future and reappointed him. It wasn’t a money issue for the patient. It was an expectation issue.

At a subsequent appointment, I could have established a doctor-patient relationship, mutually agreed on our goals for him, and completed a collaborative exam to involve him in his dental health story. And, without sales techniques, we could have proceeded with treatment on his time frame.

Unfortunately, I appeared to him as someone trying to up-sell him instead of taking care of his problem.

I viewed the contractor as a talisman for my future practice. It was a touchstone for how and what I needed to accomplish so that our practice could meet and exceed patient expectations.

Was I to continue to ask patients to lower their expectations when they weren’t met, or to establish systems that surpassed them? If you don’t know where you’re going, any road will get you there.

The contractor with a broken flipper prompted me to create a statement of my practice expectations that was communicable and demonstrable to patients and staff. That step was essential in establishing a well-trained team, which was long-term and committed, with a sense of proprietorship and community.

The consequence raised our expectations so clients didn’t need to lower theirs.

William Tracy Brown

February 2012

Thousands of people are making preparations in advance of any change in normal circumstances, to be self-reliant without assistance from outside sources. These so-called Preppers believe that financial meltdown, government takeover, breakdown of law, End-of-Times, and various conspiracy theories will occur in the near future. If you listen to talk radio, you may think that the world will soon experience Armageddon. The National Geographic Channel’s new show “Doomsday Preppers” is their highest rated program. In case you haven’t packed your “Bug Out Bag” yet, it may be prudent to look at, Abundance-The Future is Better Than You Think, by Peter Diamandis & Steven Kotler. It provides a very different view of what’s coming.

Michael Shermer reviews Abundance in The February 22, 2012 Wall Street Journal. Shermer says the book,  “argues that growing technologies have the potential not only to spread information, but to solve some of humanity’s most vexing problems.”

Here are a few examples of what the book says are occurring: Converting every word written from earliest civilization to 2003 to digital information, the total would be five exabytes. An exabyte is one quintillion bytes, or one billion gigabytes (think of the number one followed by 18 zeroes)

If you think that’s a lot of information, look at what happened between 2003 through 2010. We created five exabytes of digital information every two days.

By next year we’ll be producing five exabytes every 10 minutes. The total for 2010 of 912 exabytes is the equivalent of 18 times the amount of information contained in all the books ever written. Not only is the world changing, and the change is not just accelerating, but also the rate of the acceleration of change is itself changing.

The author’s hypothesis asserts the future is grounded in practical solutions addressing the world’s most pressing concerns: overpopulation, food, water, energy, education, health care and freedom. They suggest that “humanity is now entering a period of radical transformation where technology has the potential to significantly raise the basic standard of living for every man, woman, and child on the planet.”

Some examples of accelerating change sited are: Information: A Masai warrior with a smartphone on Google has access to more information than the president of the U.S. did just 15 years ago. Technology: Today more people have access to a cellphone than to a toilet.  Computing: In 15 years, the average $1,000 laptop is likely to be computing at the rate of the human brain. Education: The Kahn Academy’s YouTube tutorial videos with more than 2,200 topics draw two million viewings a month from online students worldwide. Medicine: The field of personalized medicine based on genetic information is growing at 15% a year. (This industry didn’t exist 10 years ago.) Aging: The population of centenarians doubles every decade.  In 2009 it was 455,000 and will reach four million by 2050.

Another aspect of Diamandis and Kotler’s thesis in Abundance is what Matt Ridley, also in the Wall Street Journal, calls “dematerializing”.  For example, if the cost of computing power goes down, the users of computing powers acquire more of it for less. Consequently, they attain a higher standard of living. Ridley gives the example of the iPhone. It weighs 1/100^th and costs 1/10^th as much as an Osborne Executive computer did in 1982, but it has150 times faster processing speed and 100,000 times the memory.

Dematerializing is happening with many products, where banking is reduced to a handful of “electrons moving on a cellphone”.  It has happened with maps, encyclopedias, cameras, books, card games, music, records and letters, to name a few.  Diamandis & Kotler believe, therefore, the future is “better than you think”.

What does Abundance have to do with the dental profession? In my view, a great deal. Without consensus, estimates of half-life of scientific knowledge are 18 months.

The future of dentistry may include:

• The adoption of digital laboratory workflow, which results in machines creating consistent high quality restorations with the microscopic precision of a highly skilled technician.
• Traditional dental impressions, like 35mm film, will be gone.
• As with other digital innovations, price will drop and quality will go up.
• 3-D printing of multiple layers of ceramic is already being done, even though it may be years before it is used in dentistry.
• Instead of surgical implants, it may be possible for stem cell technology to enable regeneration of missing teeth within the patient’s mouth. In the current technique, the stem cells are directed to a scaffold to start growing in the socket.
• Another proposed concept is a unique plan to regenerate carious lesions by implanting stem cells., which infers tissue destroyed can be restored biologically.

If successful, these examples of advanced technology in dental procedures could change the face of dentistry.

Who is right, the optimists or the pessimists? Loss aversion inspires interim thinking. Over optimistic thinking of a too rosy future can sound as implausible as end-is-near pronouncements.

The rate of acceleration of change will transform how dentistry is practiced; scientifically, clinically, technologically, and demographically. As a profession, we need to acknowledge the cognitive biases and in addition, address the obstacles we must overcome to reach so-called abundance. These changes may transmute to more and better prevention, education and dental services for those who don’t presently receive them. This would be well above what dentistry provides to a significant part of the population presently. That per se would be bounty for many who suffer from the evidence of dental disorders.

The more we change the more we are the same; the doctor-patient relationship will continue to trump technology.

However, accomplishing these outcomes will require bold leadership; personal and political. Welcome to the Brave New World. Are we prepared?

William Tracy Brown

February 2012

When recalling practice experiences, my first thoughts aren’t about the complex rehabilitation case, or the crowns, implants, or veneers I delivered. The most vivid memories are the people.

The sooner dentists learn that dentistry is about people more than teeth, the better.  The Patient-Centered Practice (RBP) is what many have touted, including Nate Kohn, Bob Barkley, Lynn Carlisle, Mike Robichaux, Don Deems, and others.

I felt a need to share what patients had taught me about RBP, but I wasn’t sure how to go about it.

My wife, Sibylla advised me to, “Write about what you can’t forget.”

It was a stroke of genius.

With that in mind, I want to offer experiences that I can’t forget.

I was an associate in my first year of practice in a working-class neighborhood with no nearby dentists.  As a result, we were more like a MASH unit.  The senior doctor and I saw patients six days a week, scheduled four patients per hour plus “squeeze-ins”, which was our aphorism for walk-ins. The office resembled an emergency room; show up and wait your turn.

Since I was usually the first person in the morning, I pulled into the parking lot with the sun just peeking over the trees. I noticed an 18-wheeler semi idling in our front lot. I parked in my spot behind the building, let myself in and unlocked the front door.

The truck driver stood outside the door.  He was 6’ 4”, broad shoulders, and narrow in the hips.  He wore a wide-brimmed cowboy hat, western shirt, Levis with a really big belt buckle and cowboy boots.  His upper lip was swollen and bloody.

As I opened the door he said, “Hey Doc.! Need to see yawl”

“What happened to you?”

“I stopped at a honky-tonk east of Denver last night, sittin’ at the bar, and some old boy said, ‘Shut Up’, an I thought he said, ‘Stand Up!”

He pushed up his fat, bloody lip to show me the two missing front teeth.  It was a terse, but accurate explanation.

I attended to this hard-working guy’s true emergency, but as I looked after him, I began questioning what I was doing. The cursory examination revealed a sea of sepsis, missing teeth, large carious lesions and infected gums. He was in his thirties and well on his way to complete dentures.  I didn’t know what to say to him.

In what manner could I present this man a practical way to take care of his oral health so he wouldn’t be wearing wheel chairs in his mouth? How could I communicate the benefits of personal oral hygiene to a trucker who lives in Oregon, stops to see me in the middle of the U.S. on his way to Florida? I wanted to help him, but I didn’t even know where to start.

As I drove home that evening, I thought about what I had learned from the trucker. Would cleaning up after a fistfight define the balance of my career?  I thought I wanted to be a diagnostician. I wanted to be a healthcare professional, not a firefighter putting out the latest flare-up in somebody’s mouth.

The incident with the young truck driver forced me to seriously consider the future of my career path.  I didn’t know how to get from Point A to Point B.

Were my patients on an endless treadmill of dental disease resulting in the ultimate failure of complete dentures?

Was I to be a dental firefighter for the next forty years?

Was I destined to be confined to the gray background of the random activity of human existence?

Questions that I had no answers.

I was looking for solutions, but my conclusions were still based on devices and tactics instead of the human spirit. Nonetheless, a dental emergency had convinced me to look within myself. I didn’t have answers, but I was asking questions.  It was the start of a journey, not a destination.

William Tracy Brown

February 2012

Like every other morning, I received an unwanted, unsubscribed email, but this one piqued my interest. It was a NEW CONCEPT: Referral Marketing & Permission Marketing.

The email explained that all marketing and advertising coming at you daily is considered an interruption by 8 of 10 adult consumers.  (I wonder, who came up with that statistic?)  The examples given of frowned upon interruptions included jack hammer outside your hotel room, huge pile of junk mail on your kitchen counter, volume increased on radio and TV commercials, spam, pop-ups, telemarketing, and people accosting you with fliers.  All of these (including the email I received) are considered unwanted interruptions.

The email goes on to say a referred patient overall, is much easier to work with, and “will buy more dentistry.” (What a scary thought!)  It continues with new patients from “permission marketing are much more likely to buy, they also stay longer and refer more.” The email says that patients who come to your office as a result of Interruption Marketing are less likely to buy, more likely to leave, and don’t refer as many friends.

The final pitch was, “Word of Mouth Marketing is the number one source for quality new patients and its here to stay.” My reaction was, “Is this novel?”  The email infers this is a new type of marketing.  I thought that Word of Mouth was the basis of a Relationship Based Practice.

The email wants “owners to contact us to increase your sales and profits.”  I am intrigued how they would do that.

• Do they recommend that the dentist and staff have a mutually agreed upon philosophy of practice that is easily understandable and repeatable?
• Are the practice goals for regular patients to keep their teeth for life and ultimately lower the incidence of dental repair?
• Does the dentist perform a comprehensive oral examination in which the patient is involved in Co-Diagnosis and Co-Discovery?
• Does the dentist collaborate with patients to understand outcomes and limitations of treatment?

It is good that a consulting company has recognized the time-honored concept of professionalism.  That a Doctor being a Teacher transforms into a well served, satisfied patient who is eager to have family and friends receive the same level care.

“When the patient leaves your office able to explain to his family and friends his relationship with you and how it benefits him, immediately and in years ahead, you have established a relationship which is the only sound basis for growth of your practice and development of your profession.”

Dr. Nathan Kohn presented the above statement to me in 1966. It was valid then and it is irrefutable today. I compliment the consultants for recognizing a fundamental truth of oral healthcare success, even though it could be construed as reinventing the wheel.

William Tracy Brown

Have you reflected about the past year?  Where have you been?  Where are you going? How do you determine the context of the movement of your practice life?

Analyzing My Practice

One of the most important vehicles for taking stock in dental practice is practice analysis. I learned the important enterprise of analyzing my professional activity shouldn’t be delegated to an outside consultant.  The process is as important as the analysis. Fortunately I was blessed with a mentor who had an innate understanding and appreciation of dentists and their practices, and with us, a working relationship with my staff and me. Understanding each of our personal identities through profiling and intercommunication developed the accord and rapport.

Dr. Nathan Kohn, Jr. impressed me on the need to complete an appraisal to become keenly aware of what I had created.  What is my practice? Where am I? He said that the record of my practice is the best evidence as to what has happened.

He provided a questionnaire designed as a self-appraisal – its movement and direction.  The primary purpose was to help me think through my situation.  It was not considered a panacea.  It was a guideline to growth, development, and progress toward goals I had expressed – some not yet on paper and not yet programmed into action.  It was a basis for decision-making.

Staff Involvement

Dr. Kohn felt it was important to have my auxiliaries assist me and participate in the appraisal.  Although the questionnaire was long, he didn’t feel it was truly comprehensive and he hoped I would include other problems that concerned or interested me.  He recommended that on some of the more detailed things, it would be good training to assign my auxiliaries to study what is happening in my practice.  This would increase their ability to understand both my and their positions.  It became apparent that the more time and effort I put on attempting to answer the questions as carefully as possible, the more help I will be able to get in the construction of an operation manual of our own.  Some of the questionnaires filled out by auxiliaries included my checking and thinking with them in terms of their answers.  This shared activity created a positive synergism within our team.

Effort = Results

We found that the importance of fully completing the analysis could not be overstated.  The benefits we received were in direct proportion to the effort we made.

In order to determine the actual nature of my impact on our patients, Dr. Kohn advised the auxiliaries fill out the forms with no estimates.  We needed exact figures.

The appraisal consisted of 58 items to be answered by our team, starting with my name, age dental school attended, how long in practice, Etc.  Starting with #8, the real work began: Describe the area in which you practice in terms of the type of people, their economic, social, and educational level____________________________

Number 12: Please outline a brief chronology of your practice listing where you began, your major moves, the year in practice that you added auxiliaries, additional auxiliaries added, and so forth.  Also give some indication of the growth of your practice during this period_______________

It is apparent that this is not the usual practice analysis.  It continued with asking about tangibles, e.g. What is the investment in your practice $__________ (Be sure to include equipment, staff training, education, housing, accounts receivable, and other intangible for which you list a dollar value.   Your total cost of professional education.  The average cost of postgraduate studies in a year; average it and list it for one year.  Your total inventory, which includes dental supplies, dental equipment office records, folders, charts, office equipment, typewriters, computers, files, office furniture.

2. Cost of installation of all this equipment and cost of planning of space, equipment planning, location planning, office records planning, office supplies planning, Equate this to a figure of so many hours which will equate to the hourly fee that you would normally charge during dentistry and arrive at a figure.

3. Assign a time-dollar equation to your selection and training procedures, which were invested in your present working auxiliaries.

4. List your total accounts receivable.

The next question was: If you assume a ten percent annual return of your investment per year and subtract this from your income, how does this make you feel about the remainder which is in effect, your income?  Excellent, consistent with my aptitude, training, and experience?_______

Adequate?_____________________  A living, but inconsistent with either my aspiration or the contribution I feel I am able to make to patients?____________

Inadequate?___________________

You can see where this is going.  By working through and answering each query accurately and completely provides the dentist and his staff a context to the cost of professional training, investments in tangible equipment, and time-dollar value, everyone in the office had a new respect, understanding, and appreciation for what we had created.  The appraisal focused on the unseen value we provided our clients in regard to the investments made for their benefit.

The final questions of the appraisal were: Without reservations, ideally where would you really like to be in your dental practice in five years?_______________________

Where do you think you will be?________________________________

Results

What did this hard, grinding work ultimately do for us?  Was it worth the effort?  Who benefited?

The answers are:  Creation of a winning unit, Yes, and Everyone (Patients, Staff, and Dentist).

The appraisal was a team effort.  An outsider who had no skin in the game didn’t do it.  We produced the results together and everyone had an opportunity to see what we had invested.  There was a truthful mutual agreement on the practice direction, not by acquiescence.

The appraisal defined our organization.  As a result we mutually developed agreed on goals.  It assisted in redefining our framework.  We established new procedures and defined a process of continuous evaluation.  It was team building in a real sense.

The first was the most difficult, but each subsequent appraisal was easier, but just as beneficial to all.

Dental practices are highly complex.

There are new roles not envisaged in dental training

The dentist can feel trapped playing roles they have no training, experience or inclination for.  The related managerial functions require communication skills.

Possibly the most significant benefit from the practice analysis was the creation of a comprehension of the roles played by each staff member.  Working through the analysis let auxiliaries appreciate some of the problems confronting the dentist that they would never have realized without the process of the study.

It has been said that Man is the only creature on earth that can talk himself into trouble.  Clear and effective communications are essential in any human interaction.  The discipline of analysis, understanding our roles and ourselves, resulted in clear lines of communications for our patients and staff.  What we accomplished improved our abilities to communicate with each other and eliminating as many “failures to communicate” as possible.    It worked for us.  It can work for you.[1]

William Tracy Brown

December 2011

Dr. Mike Robichaux has an outstanding piece in the current In A Spirit Of Caring (http://www.spiritofcaring.com/members/Two_Distinct_Dental_Visits.cfm. ) He takes the reader on an imaginative journey with a patient who kicks the tires of two dental practices.  The first office didn’t “feel right”, but the second office had a “gentle hum”.

Dr. Mike’s thoughtful and insightful piece took me back to my first practice.  It was basically a dental first aid station.  It could be described as CBA (i.e. Chrome, Blood, and Alloy).  We saw patients six days a week, from 8 AM-5 PM.  Four patients per hour plus “squeeze-ins” which was the aphorism for walk-ins.

There was no “gentle hum” just the whine of the high-speed rotors.

As I read the ISOC description, I put myself in the place of the two dentists described.  Dentist A resembled me more than I care to admit.  I followed the random paths of those who went before me and it appeared that it was basically a way of making a living.

After eighteen months, I shared my frustrations with my wife and we agreed there must be a better practice model.

The Beggar

My radical change was to open my own office.  I was even more frustrated, plus I had all the management responsibilities previously taken care of by my senior doctor.

However, my situation was like the parable of the beggar sitting on an old box asking a passing stranger, “Can you spare some change?”

“I have nothing to give you, but what’s in the box your sitting on?”

“Oh, nothing.  I’ve been sitting on it for years.”

“Why don’t you look inside?”

“Why?  It’s empty.”

The stranger insisted and the beggar pried the box open.

The box was filled with gold.

I was sitting on gold without knowing it.  Until I looked inside myself and found out who I was and what I wanted, I was looking in all the wrong places.

By looking inside, I found the person I was intended to be and what I truly wanted my practice and my life to be.  Understanding myself was the foundation for understanding others.

I was able to articulate what I believed  in a way that was easily understandable and repeatable by my patients and staff.  My written beliefs became powerful communication and management tools.  It changed everything.

My mentor, Dr. Nathan Kohn, Jr. guided me in developing a “patterned interview”  which established truly effective relationships.  My staff already knew and agreed with my beliefs and objectives, so we were able to create the “gentle hum” Dr. Mike persuasively describes. The communication of my beliefs with patients allowed them to agree on the goals and objectives of the practice.  And that became the biggest practice builder of all.

I think this is what Dr. Robichaux described with “Dr. B”.  He had looked within himself.

The Authentic Life

Dr. Robichaux and I are talking about an authentic life.

Some futurists say that people’s values are reshaping the consumer landscape, where people are rejecting the idea that consumption is going to make them happy.  Research shows that once our basic needs are met adding more money does nothing for happiness.

Andy Hines, in his book, Consumer Shift: How Changing Values Are Reshaping the Consumer Landscape makes the point that “authenticity” is one key concept which businesses would be wise to embrace as the future unfolds.  Hines explains that the evolving consumer mindset expects to be treated with respect and be told the truth, rather than misled or coddled which will lead to a greater level of appreciation from that customer.

Tenets not Tactics

What does this have with “Dr. A & Dr. B”?  Everything.  I believe, being able to determine my own tenets instead of following the tactics of others led me to an authentic life.  I truly owned an authentic life and practice.

Is The Patient-Centered Practice Obsolete?

Former UK Prime Minister Margaret Thatcher quoted the World War II slogan, “It all depends on me.”  making the point it seems that people have forgotten that, and they think it all depends on the other person. It all does depend on you.

It appears the Patient-Centered practice that Dr. Robichaux so eloquently describes is more relevant today than ever.  And, it all depends on you.  Knowing yourself, articulating your beliefs to patients and staff in a manner that is easily understandable and repeatable creates the authentic practice.  The practice that puts the patient first.  The practice that isn’t based on arbitrary production goals, but based on what is best for the individual patient.

To me, this is how dentistry changes the conversation with our consumers and re-establishes the authentic doctor-patient relationship that is the only sound basis for growth of our practices and development of our profession.

(Note:  See today’s Wall Street Journal Article, “If Your Teeth Could Talk…” http://online.wsj.com/article/SB10001424052970203686204577112893077146940.html?mod=ITP_personaljournal_0

The concepts embodied herein may be the future of dental practice.Be sure to read the “comments”.WB)

December 2011-Blog

William Tracy Brown

The November 28, 2011 article in the New York Times by Ritchie S. King, “A Closer Look at Teeth May Mean More Fillings” could be considered an “expose”.  I use that term because the first part of the story cites the increasingly sophisticated detection technology results in dentists finding–and treating–tooth abnormalities that may or may not develop into cavities.  The reporter says that, “some describe their efforts as a proactive strategy to protect patients from harm, critics say the procedures are unnecessary and painful, and driving up the costs of care.”

The implications in the article are that dentists are treating tooth abnormalities that may or may not develop into cavities.  A dental professor is quoted as saying, “A better approach is watchful waiting.  Examine it again in six months.”  The professor added that every time a dentist drills a tooth you’re condemning that person to a refilling years down the road.

Another dental expert thinks that “watchful waiting” doesn’t make sense.  He uses the analogy of a physician diagnosing risk factors for heart disease and then taking action to treat the early signs of disease to try to prevent further disease.  The expert mentions the fact that incipient caries can’t always be seen with radiographs or the naked eye.  He mentions the use of Diagnodent, but does not discuss Kodak Logicon, software that helps dentist visually analyze and diagnose carious lesions on proximal surfaces.

Logicon Diagnostic Imaging

 Risk factors are discussed, but no mention was made of studies done by Dr. Sumter Arnim which involved teaching patients how to manage microfilms and diet.  Dr. Arnim observed patients with interproximal carious lesions which re-calcified and did not progress over many years without dental restoration, only meticulous personal oral hygiene.

Even though it was balanced reporting, the implication in the NY Time’s piece was dentists were finding more things to drill and fill for the dentist’s benefit, not the patient’s.

What do you think?

Addendum:

It would have been beneficial for the NY Times reporter to have had the historical and scientific basis for dental disease prevention.

Dr. Arnim wrote in, “Thoughts Concerning Cause, Pathogenesis, Treatment and Prevention of Periodontal Disease”, The Jour. of Perio, Vol. 29, pp 217-223, July, 1958., “The essential factor in the program for prevention is found in the education of the patient by the dentist. The patient must know periodontal disease is caused by the periodontal microcosm……The patient’s responsibility for the success of prevention of periodontal disease must be stressed. It is this combination of intelligent understanding and clinical application of basic knowledge concerning the etiology and pathogenesis of periodontal disease which leads to successful treatment and prevention”.

Dr. Arnim also determined that the production of caries was highly diet related,especially to carbohydrates, therefore, he recommended the decrease in the frequency (not the amount) of sugar foods, if caries was the problem.  Arnim applied the water irrigation principle for wound debridement to flush the wastes (toxins, enzymes) from periodontal pockets. This, or some other method of plaque control must be used where periodontal pockets exist.

If patients can control microfilms or plaque to control periodontal disease, they will not have dental caries except in unmanageable areas.

                                                                               Dr. Arnim in his lab.

November 2011-Blog

The Ideal Dental School

“Only Wet Newborns Embrace Change”

I received an intriguing phone call this week from a colleague, a former general practitioner and presently a dental school professor.

I have known him for several years and have been impressed with his erudition, critical thinking, passion and dedication to the development of the next generation of dentists.  In my estimation, he is the best of the best.  He wishes to consider reasoned revisions of current dental education and practice models.

My colleague reached out for help in the development of a new dental curriculum for dental schools.  Believing that everything we do can be improved, he proposes to create innovative pre-dental educational requirements, a more-precisely focused student selection strategy, and a modernized, more effective dental curriculum to train dentists for the 21st Century.  My friend offered the caveat, “Only wet newborns embrace change.”  But change is inevitable, and here is a chance to make a difference.

 This is a Big Deal.

Imagine, if you could designing the ideal or near-perfect dental school.  How would you do that?  What would you change?  What would you include?  What would you delete?  What criteria would you use for student selection?

I think you see where this is going.  We want your help.

Would you share all thoughts and ideas you would include and/or eliminate in this model dental school?  Recall your days in dental school?  What and who was inspirational?  What was demeaning?  What did you love?  What did you dislike?  How could a new dental school include the good and eliminate the bad?

Should there be a change in pre-dental curriculum to include the basic sciences, i.e. biochemistry, physiology, pharmacology, histology, etc.?    Should undergraduate courses in areas such as human behavior, money and banking, philosophy and ethics, be added to dental pre-requisites?  Should courses focus on deeper understanding of human behavior and motivation; on interpersonal and communication skills; on effective methods to assist patients make better choices for optimal health, appearance, and function?  Should there be personality profiling to uncover applicants who have limited empathy?  Should there be an admissions process that involves a series of encounters meant to examine a dentist’s ability to communicate and work in teams instead of a single encounter with hackneyed questions?

Instead of relying strictly on college grades, dental aptitude scores and responses to canned questions, should Multiple Mini Interviews (M.M.I’s) be utilized? (See DI blog http://www.dental-intelligence.com/2011/07)   Should methods be employed to determine applicant’s communication skills, which are so important for any healthcare professional?

Should dentists graduate with the knowledge and skill to place a high-quality amalgam, cast gold crown, cast gold inlay/onlay, and complete denture?   Bonded restorations? Acceptable endodontic procedures? Implant placement and restoration? Should emphasis be placed on the dentist presenting diagnoses based on Comprehensive Oral Examination performed by the dentist and not auxiliaries? Should there be comprehensive care and management of geriatric patients? What, indeed, should be the minimal expectations of a dental graduate of the 21^st Century?

Should there be renewed emphasis on achieving an orthopedically stabile occlusion and a healthy periodontium BEFORE attempting to develop a definitive treatment plan?  Should acceptable levels of patient compliance be required before treatment can begin?

Should there be training in the fundamentals of banking and financial planning?

The list grows as one considers the implications and possibilities.

My hope is that you will join me in sharing your thoughts on what you would offer as a curriculum to an ideal dental school, including the undergraduate experience as well as the post-doctoral years of life-long learning.  The best school you can imagine.

I think all of you also embrace change. Thanks in advance for helping, and please invite your own friends who think we can always do things better to join the group!

I will compile the ideas I receive and share them with you and with this dedicated and committed dental professor.  Our ideas will be welcomed in this important process.

Thanks, in advance.

Blog-2011

 DHATS-The Answer To Dental Access?

William Tracy Brown

Peter Drucker, makes the prescient observation in his 1968 book, The Age of Discontinuity.  He says, if you are only paid for what you do with your hands, someone will do it cheaper.  This statement is really the basis for the concept of the DHAT (Dental Health Aide Therapist or Mid-Level Therapist), i.e. someone to do the dental treatment cheaper than the dentist.

You can view this issue from several different perspectives:

Why not have several levels of care for patients.  It is happening in medicine with nurse practitioners.  A front-page announcement in our local weekly newspaper about a nurse opening her medical office referred to “Doctor” so-and-so.

Doctor Doctor  

The October 1, 2011 New York Times has an article by Gardiner Harris (http://www.nytimes.com/2011/10/02/health/policy/02docs.html?_r=1&emc=eta1) regarding the number of nurses, pharmacists, and physical therapists who are earning “doctorates” so they can have the title of “doctor” along with the prestige and money.

We have a misdistribution of dentists.  After training, not many want to move to small towns or rural settings.  So why not have someone with a couple of years training do the “routine” drilling, filling, and billing?  It’s not so hard.

Or is it?

What is a routine filling or extraction?  How do you know it is going to be routine?

How did a “routine” extraction turn into 2 hours of hell for the patient and the dentist?  How do you predict what is going to happen?

You don’t.  And that is really the point.  The extensive training is for taking care of the unexpected.  The presumed simple procedure that suddenly turns very complex is routine.

The Mouth Is An Organ System

How do you train someone in a few months to develop the care, skill, and judgment necessary to treat an organ system that is as much a medical specialty as ophthalmology or otolaryngology?

Should these mid-level providers be under the direct supervision of a dentist or should they have independent practices? Will there be a new era of Tele-Dentistry?

Who manages medical emergencies?

The Reason For Professional Education

The critical question is: Who is responsible for the diagnostic algorithms?  In my view, diagnosis is the reason for a professional education.  Synthesizing the biologic, scientific, technical, and behavioral science to determine an explicit protocol to solve a patient’s oral healthcare problem.

Can that be learned in a few months coupled with a few years of dental hygiene practice?  I would not want a member of my family treated by that level of care.

Hygienists tell me they are already doing the examinations and diagnosis of patients.  The dentist comes in after the fact for a drive-by exam and looks for holes and spaces to fill.  The hygienists argue, “Why shouldn’t we practice independently? We are already doing exams, diagnosis, and treatment.”

Fighting for more autonomy by auxiliaries is nothing new, but it has relevance to the issue of Mid-Level Therapists.  Hygienists see an opportunity to treat patients first and stop dentists from being the sole gatekeepers of dental patients.

Who Leads the Team?

 The argument put forth by physicians in the struggle with nurse practitioners is that the physician’s training is so extensive that they alone should diagnose illness.  Does that ring a bell?

Is the next logical step in the erosion of quality in U.S. healthcare to have dentists start practicing neurosurgery?

Prescription for Confusion

 According to the NY Times article, last year 153 nursing schools gave doctor of nursing practice degrees to 7,037 nurses.

Patients are confused with who is in charge of their care.  Who is the Doctor?

Healthcare economists say that talk of improving access to care and bending the cost curve and creating team-based care isn’t advanced by requiring students to spend more time and money getting trained.  They say this extra training will invariably result in longer waits and increased costs, because those who meet increased requirements will eventually demand higher compensation.

Scope of Practice

 In my view, the dentists with the training should be the captains of the ship.

The dentists should examine, diagnose, and plan treatment.

The dentists should be responsible for the quality and effectiveness of all treatment.

Some Public Health dentists are touting DHAT’s as a way to expand private practices volume, like adding more hygienists.  They suggest that this model would be an excellent way for dentists to make more money.

The first contract is always the best. Is this the proverbial,  “nose of the camel in the tent”?

Will DHAT’s have medical liability?  Will DHAT’s maintain the fidelity of quality care?  Will an independent Mid-Level practitioner have lower overheads?  Will the rent be lower? Will salaries be lower? Will lab and supplies be less?  Will the DHAT”S be required to stay in the remote areas permanently by government mandate?

Have you heard cogent answers to these questions?

 Who Wants DHAT’s?

 The major push comes from:

• National Academy for State Health Policy (NASHP)
• Kellogg Foundation ($16 million initiative for five states to form coalitions to develop programs.)
• Josiah Macy, Jr. Foundation in partnership with the American Association of Public Health Dentistry (AAPHD) to create a two year post secondary training and curriculum.
• HHS-HRSA

The Kellogg Foundation states, “The primary goal of instituting dental therapists and hygienists-therapists in the U.S. is to expand availability of basic dental services to socially disadvantaged sub-populations that are now inadequately served.”

Denise Bowen, writing in the Journal of the American Dental Hygiene Association, “Solutions to the nation’s oral health problems will demand innovation and leadership.  Removing barriers and instituting change to expand and maintain an adequate oral health workforce, especially for special needs population, is critical.”

State legislatures are supporting the formation of DHAT’s over the objections of State Dental Boards, the ADA, and AGD.

What are resolutions for under-served citizens?

 In the United Kingdom, I toured a dental school clinic.  The largest department, both physically and staff, was exodontia and removable prosthodontics.

Why?

Getting rid of the teeth and making false replacement was the ultimate solution for the sea of sepsis that the dental profession was confronted with.

The Bristol, England newspaper featured a shock report of 11 year old girls having full-mouth extractions and dentures.

All care was free under the National Health Services (which some wags called the National Sepsis Service), but the dentists and the government funded program was so inundated with dental disease, resolution was getting rid of the teeth, artificial replacements, and the government’s responsibility was ended.  The citizens were left lifetime dental cripples to deal with dentures that were inadequate, uncomfortable, and never going to improve.

Dental Disease Is Predictable

We know the cause and how to control dental disease.  It takes behavioral change, and understanding your enemy i.e. public education.

A major difference between dentistry and medicine is if patients have routine professional care coupled with education and necessary skills to control their dental disease, caries and periodontal disease become elective.  These measures are proven to be cost effective and realizable, whereas people can stop smoking, exercise, have healthy diets, and still end up with cancer, cardio-vascular disease, and diabetes.

Instead of training a large cadre of dental nurses to perform diagnostic and irreversible procedures, to patch the ravages of disease, the investment should be in education and monitoring of predictable dental disease prevention.

The touting of DHAT’s as a solution is like calling the carpenters when your house is on fire.  You can’t drive nails that fast.  Wouldn’t it make more sense to call the fire department first?  When Amer-Indian reservation statistics cite 90% caries incidence in resident children, wouldn’t effective disease prevention systems be a viable solution?

16 Dental Schools Planned

Currently, three new dental schools are accepting a 2011 entering class, four schools are scheduled for future opening, and nine schools are analyzing feasibility.

Our country has massive debt.  A serious presidential candidate has proposed closing Departments of Commerce, Education, Energy, HUD, Interior and the TSA to try to deal with our dire financial straits.  Where will the funding come for these new training programs for dental nurses?  How will the new clinics and support staff be funded?

Dental school four-year tuition at 56 dental schools has at the top $310,458 and the lowest is $63,003. The projected expenses for four years at the University of Iowa: $178,986.81 for residents and $264,488.81 for non-residents.  That is near the middle of the pack.  This figure does not include living expenses.

Will the government mandate dentistry as a public utility?  No one thought that the Federal Congress and President would mandate all citizens to purchase healthcare coverage.

Solving The Problem

 Creation of DHAT’s appears to be a government solution to a problem of access.

Shouldn’t the dental profession offer their answer to this acute concern?

A national program could be developed to assist the public in becoming aware of their personal responsibility in dental prevention.  This could be done in similar fashion to the anti-smoking campaigns, using mass media.

Comprehensive action will be necessary to accomplish the undertaking.  It may include the dental profession establishing strategic alliances with dental educators, dental associations, dental manufactures, marketing-media-communications professionals, non-profit foundations, etc. to formulate a broad application of preventive science and behavioral consideration.

The plan cannot be a “one-size-fits-all”.  We are confronted with an extremely complex question and unstudied solutions won’t solve it.

The existing disease in vulnerable citizens and under-served areas could be treated by teams headed by dentists encouraged by a student loan reduction plan for service.

In urban areas, dentistry must have fees that are at least break-even so dentists aren’t financially penalized for treating public-aid patients.  Is there evidence of government employed dentists or dental educators contributing significant personal financial resources to mitigate the dilemma?

A national education program aimed at patient responsibility for dental disease control coupled with dental offices dedicated to making unmanageable areas manageable would go a long way to ameliorating the current problem.  This could be done without a duplication of training of a second level of dental care for our citizens.

There are massive public education programs for tobacco cessation, seat belt use, impaired driving, obesity, etc.  Doesn’t it make sense to have a truly effective campaign for control and prevention of man’s most common disease?

Who can do a better job of providing the education of our citizens than the dental profession?  A private practice solution can be more effective and less costly than a government plan.